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Beauchamp MH, Dégeilh F, Rose SC. Improving outcome after paediatric concussion: challenges and possibilities. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:728-740. [PMID: 37734775 DOI: 10.1016/s2352-4642(23)00193-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/12/2023] [Accepted: 07/17/2023] [Indexed: 09/23/2023]
Abstract
The term concussion has permeated mainstream media and household vocabulary mainly due to awareness regarding the risks of concussion in professional contact sports, yet it occurs across a variety of settings and ages. Concussion is prevalent in infants, preschoolers, children, and adolescents, and is a common presentation or reason for referral to primary care providers, emergency departments, and specialised trauma clinics. Its broad range of symptoms and sequelae vary according to multiple individual, environmental, and clinical factors and can lead to health and economic burden. More than 20 years of research into risk factors and consequences of paediatric concussion has revealed as many questions as answers, and scientific work and clinical cases continue to expose its complexity and heterogeneity. In this Review, we present empirical evidence for improving outcome after paediatric concussion. We consider work pertaining to both sports and other injury mechanisms to provide a perspective that should be viewed as complementary to publications focused specifically on sports concussion. Contemporary challenges in prevention, diagnosis, prognosis, and intervention are discussed alongside pathways and future directions for improving outcome.
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Affiliation(s)
- Miriam H Beauchamp
- Sainte-Justine Research Center, University of Montreal, Montréal, QC, Canada; Department of Psychology, University of Montreal, Montréal, QC, Canada.
| | - Fanny Dégeilh
- Univ Rennes, CNRS, Inria, Inserm, IRISA UMR 6074, EMPENN ERL U-1228, Rennes, France
| | - Sean C Rose
- Pediatric Neurology, Nationwide Children's Hospital, Columbus, OH, USA; Ohio State University College of Medicine, Columbus, OH, USA
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Yeates KO, Barlow KM, Wright B, Tang K, Barrett O, Berdusco E, Black AM, Clark B, Conradi A, Godfrey H, Kolstad AT, Ly A, Mikrogianakis A, Purser R, Schneider K, Stang AS, Zemek R, Zwicker JD, Johnson DW. Health care impact of implementing a clinical pathway for acute care of pediatric concussion: a stepped wedge, cluster randomised trial. CAN J EMERG MED 2023; 25:627-636. [PMID: 37351798 PMCID: PMC10333406 DOI: 10.1007/s43678-023-00530-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/23/2023] [Indexed: 06/24/2023]
Abstract
OBJECTIVES To test the effects of actively implementing a clinical pathway for acute care of pediatric concussion on health care utilization and costs. METHODS Stepped wedge, cluster randomized trial of a clinical pathway, conducted in 5 emergency departments (ED) in Alberta, Canada from February 1 to November 30, 2019. The clinical pathway emphasized standardized assessment of risk for persistent symptoms, provision of consistent information to patients and families, and referral for outpatient follow-up. De-identified administrative data measured 6 outcomes: ED return visits; outpatient follow-up visits; length of ED stay, including total time, time from triage to physician initial assessment, and time from physician initial assessment to disposition; and total physician claims in an episode of care. RESULTS A total of 2878 unique patients (1164 female, 1713 male) aged 5-17 years (median 11.00, IQR 8, 14) met case criteria. They completed 3009 visits to the 5 sites and 781 follow-up visits to outpatient care, constituting 2910 episodes of care. Implementation did not alter the likelihood of an ED return visit (OR 0.77, 95% CI 0.39, 1.52), but increased the likelihood of outpatient follow-up visits (OR 1.84, 95% CI 1.19, 2.85). Total length of ED stay was unchanged, but time from physician initial assessment to disposition decreased significantly (mean change - 23.76 min, 95% CI - 37.99, - 9.52). Total physician claims increased significantly at only 1 of 5 sites. CONCLUSIONS Implementation of a clinical pathway in the ED increased outpatient follow-up and reduced the time from physician initial assessment to disposition, without increasing physician costs. Implementation of a clinical pathway can align acute care of pediatric concussion more closely with existing clinical practice guidelines while making care more efficient. TRIAL REGISTRATION ClinicalTrials.gov NCT05095012.
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Affiliation(s)
- Keith Owen Yeates
- Department of Psychology, University of Calgary, 2500 University Dr. NW, Calgary, AB, T2N1N4, Canada.
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.
| | - Karen M Barlow
- Child Health Research Centre, Queensland Children's Hospital, University of Queensland, South Brisbane, Australia
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Bruce Wright
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
- Women's and Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - Ken Tang
- Independent Statistical Consulting, Vancouver, BC, Canada
| | | | - Edward Berdusco
- Departments of Emergency Medicine and Family Medicine, University of Alberta, Edmonton, AB, Canada
| | - Amanda M Black
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Faculty of Kinesiology, Sport Injury Prevention Research Centre, University of Calgary, Calgary, AB, Canada
| | - Brenda Clark
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Alf Conradi
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Heather Godfrey
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Department of Emergency Medicine, Alberta Children's Hospital, Calgary, AB, Canada
| | - Ashley T Kolstad
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Faculty of Kinesiology, Sport Injury Prevention Research Centre, University of Calgary, Calgary, AB, Canada
| | - Anh Ly
- Department of Psychology, University of Calgary, 2500 University Dr. NW, Calgary, AB, T2N1N4, Canada
| | | | - Ross Purser
- Department of Emergency Medicine, Grey Nuns Hospital, Edmonton, AB, Canada
| | - Kathryn Schneider
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Faculty of Kinesiology, Sport Injury Prevention Research Centre, University of Calgary, Calgary, AB, Canada
| | - Antonia S Stang
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
- Department of Emergency Medicine, Alberta Children's Hospital, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Roger Zemek
- Departments of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Jennifer D Zwicker
- School of Public Policy, University of Calgary, Calgary, AB, Canada
- Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| | - David W Johnson
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
- Department of Emergency Medicine, Alberta Children's Hospital, Calgary, AB, Canada
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
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